Repair of aortoesophageal fistula after aortic grafting

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.     

Spatial W-plasty full-thickness skin graft for neovaginal reconstruction

Although neovaginal reconstruction has achieved satisfactory results, there is still room for refinement and improvement. Despite its popularity, McIndoe's inlay split-thickness skin graft method still has several significant drawbacks. Here a new approach to neovaginal reconstruction by using a full-thickness skin graft displayed in the fashion of spatial W-plasty is described. Our idea combines the advantages of a full-thickness skin graft and Z-plasty principle in clinical practice. Four patients who had been reconstructed with this method had satisfactory results with minimal secondary contracture and unilateral linear groin scar. Three of them have married and enjoy sexual life without difficulties. The fourth patient has not married but shows no contracture in follow-up examinations. Since the result is encouraging, this method deserves wider clinical application.     

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.     

Microscopic and energy dipersive x-ray analysis of surface adaptation of dental cements to dental ceramic surfaces

The authors present a retrospective study on 30 patients with prosthetic graft infection. Included are 25 patients with aortic graft infection, three with infection of a femorodistal bypass and two with infected axillofemoral grafts. There were 23 isolated primary prosthetic graft infections and seven aorto-enteric fistulas. Treatment consisted of graft excision and replacement with cryopreserved arterial homografts, harvested from brain-death multi-organ donors. The in situ technique was used in 27 cases. Eight patients died postoperatively and two deaths were from allograft related complications. The operative mortality rate was 11% for isolated aortic graft sepsis and the early limb salvage rate was 100%. Persistent or recurrent infection was noted in two cases. The mean follow-up of the series was 24.5 months and occlusive complications occurred in five patients (23%), which resulted in two major amputations. Serial CT scans showed abnormalities in six of the 22 survivors, all of them related to the aortic segment of the allograft. It is concluded that in situ reconstruction with cryopreserved arterial allografts represents an acceptable alternative, especially in the treatment of isolated aortic graft sepsis. Continued follow-up towards late deterioration and/or occlusive complications remains mandatory.     

Antigen specificity of antihistone antibodies in localized scleroderma

BACKGROUND AND DESIGN: Recently, we detected antihistone antibodies (AHAs) in patients with localized scleroderma. However, the exact antigen specificity of AHAs in this disease is still unknown. Therefore, we determined the reactivity of AHAs with five individual histones and the correlation of AHAs with rheumatoid factor in localized scleroderma by means of enzyme-linked immunosorbent assay. Twenty patients with localized scleroderma who had IgG and/or IgM AHAs, as determined by enzyme-linked immunosorbent assay, were examined. These patients were classified into the following three subgroups: patients with generalized morphea (n = 11), patients with linear scleroderma (n = 6), and patients with morphea (n = 3). RESULTS: In generalized morphea, IgG AHAs strongly reacted with histones H1, H2A, and H2B; and IgM AHAs strongly reacted with H1 and H2B, as determined by means of enzyme-linked immunosorbent assay. The pattern of reactivity in linear scleroderma and morphea was similar to that in generalized morphea. A homogeneous immunofluorescent pattern on HEp-2 cells, which was produced by localized scleroderma sera, was completely abolished by absorption with total histones. By employing a latex agglutination test, IgM rheumatoid factor was detected in 60% of the 20 patients with localized scleroderma and at a frequency of 82% in those with generalized morphea. However, an absorption test of rheumatoid factor activity with human IgG revealed no cross-reactivity of AHAs with rheumatoid factor. CONCLUSIONS: Our data suggest that AHAs in localized scleroderma are directed against native chromatin, since H1, H2A, and H2B occupy a relatively exposed portion of chromatin.     

Imaging subcutaneous atrophy in circumscribed scleroderma with 20 MHz B-scan ultrasound

The technique of 20-MHz B-scan sonography is non-invasive and allows quantification of the different compartments of the skin. Seven patients with atrophic linear circumscribed scleroderma and one patient with guttate circumscribed scleroderma were examined by ultrasound. All patients were found to have a total or subtotal loss of subcutaneous fatty tissue, whereas the thickness of the dermis remained almost unchanged. These findings should lead to further investigation of the pathophysiological mechanism involved in subcutaneous atrophy in circumscribed scleroderma.     

Role of the first aspartate residue of the "YxDTDS" motif of phi29 DNA polymerase as a metal ligand during both TP-primed and DNA-primed DNA synthesis

Neurofibromatosis is a systemic disease that often produces striking disfigurement. Orbital manifestations are common and include sphenoid dysplasia with or without infiltration of the periorbital soft tissues. The resultant deficiency of the posterolateral orbital wall may lead to protrusion of the temporal lobe into the orbit, displacement of the globe, and pulsatile exophthalmos. Treatment at our unit has consisted of transcranial orbital reconstruction with bone grafts and periorbital soft-tissue correction. Observation of complete bone graft resorption in one patient prompted an assessment of the Australian Craniofacial Unit's experience with particular attention paid to the stability of operative correction. Of 36 patients with head and neck neurofibromatosis treated during the period from 1981 to 1995, 14 patients underwent transcranial correction of orbital deformities secondary to sphenoid dysplasia. The treatment and outcomes of this transcranial group are reviewed. The most notable finding was that of recurrent globe pulsation in four patients following initial resolution. Computed tomography scans have documented partial to complete bone graft resorption in three of these patients. Titanium mesh is now being utilized to provide a more durable reconstruction.     

Cognitive testing

Melorheostosis is a very rare bone disease of unknown etiology characterised by linear hyperostosis and associated with fibrosis of soft tissues and the skin. This uncommon sclerosing bone dysplasia was first described by Leri and Joanny in 1922, and since then, until 1993, approximately 300 cases were reported in the literature. Linear scleroderma is a localised proliferation of connective tissue and has rarely been associated with melorheostosis. In this paper, we present a new case of melorheostosis with linear scleroderma which, to the best of our knowledge, is the first case reported in Turkey.     

Intravital microscopy and capillaroscopically guided nail fold biopsy in scleroderma

OBJECTIVES: To describe the frequency, extent, and nature of microvascular lesions in patients with scleroderma by means of capillaroscopy and capillaroscopically guided nail fold biopsy, and to determine the diagnostic value of the two methods and the pathophysiological significance of the lesions described. METHODS: A cohort study was made of 24 consecutive patients with scleroderma and 10 healthy controls, using standardised clinical, serological, capillaroscopic, and histological (nail fold biopsy) techniques. RESULTS: All patients with scleroderma had distinct lesions of the microvascular system. Capillaroscopy revealed more than 90% of the patients to have the typical scleroderma pattern. Histologically, these changes most frequently consisted of splitting of the basal lamina, broadening of the perivascular connective tissue, perivascular round cell infiltrations, and immunoglobulin deposits (each in 60-75% of the patients). Electron microscopy was the most sensitive method of histological examination, detecting abnormalities in 87.5% of patients; with light microscopy and immunohistochemical techniques, abnormalities were revealed less frequently (83.3% and 75%, respectively). In contrast, normal findings were observed in most of the healthy controls: capillaroscopy = 90%; histology = 80%. CONCLUSIONS: Microvascular lesions are a predominant feature in scleroderma and seem to have a central pathogenetic role in the disease. Capillaroscopy is able to identify this microangiopathy noninvasively, and capillaroscopically guided nail fold biopsy can detect the frequency and nature of the underlying ultrastructural changes. This may therefore be a useful tool in describing the pathogenetic role of the microvascular system in scleroderma.     

Composite resection and reconstruction for oral cavity and oropharynx cancer. A functional approach

Composite resection, the standard surgical approach for treating cancer of the oral cavity and oropharynx, results in considerable functional and cosmetic deformity, whether primary closure or flap reconstruction is employed. To minimize these problems, an alternate surgical approach has been developed. Essentials of the procedure include use of a non-lip-splitting visor flap for exposure and excision of the lesion, reconstruction with a skin or dermis graft formed into a pouch to fill dead space created by resection, and routine use of intermaxillary fixation for immobilization of the reconstructed area. In 16 patients undergoing this procedure, the approach had no adverse effect on short-term survival. Complication rate with skin and dermis graft reconstruction was acceptably low. Cosmetic improvement has been gratifying. Skin or dermis graft reconstruction has resulted in very satisfactory functional results in terms of tongue mobility, articulation, mastication, and swallowing.     

Combination of an island advancement flap and a composite graft for reconstruction of the nasolabial defect

BACKGROUND: The alar region is one of the most difficult areas of the face to reconstruct. Up until now, various methods have been demonstrated for achieving the best possible results in terms of cosmetic appearance and function. This report deals with a combination of a random pattern flap and a free composite graft, carried out in two stages. OBJECTIVE: In order to reconstruct the alar region, an island advancement flap as well as a composite graft from the contralateral ear were used. METHODS: The defect in the cheek-upper lip region was closed using an island advancement flap. In a second operation 2 weeks later, the reconstruction of the alar region was attempted using a composite graft from the right ear. RESULTS: The reconstruction of the contour of the wing of the nose succeeded in a satisfactory manner. There are no functional restrictions on nose breathing. CONCLUSIONS: The combination of an island advancement flap with a composite graft from the ear for the reconstruction of the alar region is essentially a less invasive operation that can be carried out under local anaesthesia and that represents an addition to the previously stated methods.     

Surgical reconstruction of the contracted eye socket and orbitozygomatic hypoplasia in a one-stage operation

To correct the contracted eye socket and orbitozygomatic hypoplasia simultaneously secondary to previous surgery and radiotherapy, we employed a one-stage surgical reconstruction that used a postauricular skin flap and temporal fascial flap, which were rotated for eye socket reconstruction and bone graft coverage. Hydroxyapatite was inserted as an onlay bone graft substitute to enlarge the orbitozygomatic region. In our 12-case experience the results were satisfying and encouraging with minor complications, which are presented.     

Reconstruction for palmar skin defects of the digits and hand using plantar dermal grafting

The plantar skin is considered suitable for skin grafting onto the volar aspect of the digits and hand. However, this method is not widely used because it is associated with problems at the donor site. To solve these problems, a new method was developed in which two different layers of the plantar skin are harvested from the same site. In this method, a split-thickness skin graft of the upper layer including the corneal layer of epidermis and a dermal graft of the lower layer are harvested from the same plantar skin. The split-thickness skin graft is returned to the original donor site, whereas the dermal graft is used for the palmar skin defects on the digits and hand. To prevent drying, the dermal graft was covered with a wound-covering material to achieve good graft takes. Reconstruction was performed for 17 patients using this method, involving digit-only reconstruction in 8 patients, and wider reconstruction in the other 9. Excellent color and texture match of the graft and donor sites were obtained with no noticeable marginal scarring, and the durability of the skin was satisfactory. This method was useful for skin grafting to the digits and palms with minimal sacrifice to the donor site.     

Homoeopathy for delayed onset muscle soreness: a randomised double blind placebo controlled trial

This report describes a technique for the reconstruction of a patellar tendon-tibial tubercle deficiency. This technique uses an easy-to-harvest, low-morbidity graft (autogenous quadriceps tendon), while allowing aggressive rehabilitation as a result of the strength of the graft.     

Unilateral linear lichen sclerosus et atrophicus

We report on a 23-year-old woman with unilateral lichen sclerosus et atrophicus (LSA) who exhibited extensive eruptions on the right extremities and right aspect of the abdomen. The lesions on the right extremities appeared to exhibit a linear pattern along Blaschko's lines, while the right abdominal skin lesion was a whitish, parchment-like plaque. Histological findings for both lesions showed characteristic features of LSA. LSA should be differentiated from the linear type and the macular type of localized scleroderma.     

Rupture to the skin of atheromatous aneurysm on a femoropopliteal venous bypass using an in situ vein

Atheromatous aneurysmal degeneration of a venous bypass graft is a rare and late event after venous bypass grafting. We report the case of a 49-year-old man in whom a large aneurysm of a saphenous graft implanted 10 years earlier ruptured to the skin. Amputation was required. Graft degeneration can lead to complications which may be life or limb-threatening due to graft rupture, graft thrombosis or distal embolization. Close follow-up after arterial reconstruction using a vein graft is therefore highly warranted for early detection and correction of any abnormalities before onset of complications.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament

Anterior cruciate ligament (ACL) reconstruction using four-strand hamstring graft with round-headed, cannulated, interference (RCI) screw fixation requires osteointegration of the tendon graft. This report describes the histology at the bone-tendon junction of two specimens retrieved from patients undergoing revision surgery after traumatic mid-substance ACL graft rupture at 6 and 10 weeks after initial reconstruction. Revision was performed at 12 and 15 weeks. Integration of the graft was evident by observation of collagen fiber continuity between bone and tendon. This histology plus the low incidence of early graft failure suggest that free tendon autograft attached to bone by RCI screw allows adequate osteointegration between 6 and 15 weeks after surgery.     

Thumb reconstruction with a free neurovascular wrap-around flap from the big toe: long-term follow-up of thirty cases

From March 1982 to December 1992, 30 cases of thumb reconstruction with a free neurovascular wrap-around flap from the big toe were performed at Korea University Hospital. Twenty-nine of a total of 30 cases were successful and obtained excellent functional and cosmetic results. Postoperative complications included 1 case of graft failure, 6 partial skin necroses, 1 malunion, and 15 cases of resorption of iliac bone graft including 1 case of fatigue fracture of grafted bone. Even for the first metacarpal neck amputations, thumb reconstruction with a free neurovascular wrap-around flap was possible; however, limitation of motion of the reconstructed thumb and resorption of the grafted bone occurred. Thumb reconstruction with a wrap-around free flap from the big toe gives excellent cosmetic and functional results and causes minimal morbidity on the donor site.     

Reconstruction of the breast after mastectomy for carcinoma

During the last 5 years, 80 patients underwent reconstruction of the breast as a primary or secondary procedure after mastectomy for carcinoma. Breast mounds were reconstructed with the silicone breast implant. A Silastic implant corrected the infraclavicular axillary deformity after radical mastectomy. The nipple-areolar complex was created either with a nipple-areolar graft from the contralateral breast or with a labial free graft in a bilateral breast reconstruction. If the contralateral breast was large or ptotic, reduction mammoplasty or mastopexy was performed. Subcutaneous mastectomy or total mastectomy of the other breast with insertion of the silicone breast implant was the method of choice for a group of high-risk patients.